University of Maryland School of Nursing, Baltimore, MD 21201, USA.
Womens Health Issues. 2012 Jan-Feb;22(1):e73-81. doi: 10.1016/j.whi.2011.06.005. Epub 2011 Aug 23.
Advanced practice nurses (APNs) in the United States could expand access to high-quality health care, particularly for underserved populations. Yet, there has been limited synthesis of the evidence related to their effectiveness as compared with other providers. The study reported here, part of a larger study that examined all four types of APNs, compares the labor and delivery care outcomes of certified nurse-midwives (CNMs) and physicians.
PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Proquest (for dissertations), were searched for the years 1990 through 2008.
Only those articles where processes or outcomes of care were quantitatively compared between CNMs and physicians were included. For all APNs, 27,993 citations were reviewed. For CNMs, 21 articles representing 18 unique studies reported either infant or maternal outcomes.
The systematic review followed established procedures (replicable search of relevant databases, sequential review to identify eligible studies, abstraction by two reviewers, assessment of quality, and grading of evidence).
For measures that relate to the processes of care (e.g., epidural, labor induction, episiotomy), lower use was found for CNMs. For many of the infant outcomes (e.g., low Apgar, low birth weight, neonatal intensive care unit admission), there were no differences between physicians and CNMs. Perineal lacerations were lower and breastfeeding was higher among women cared for by CNMs compared with physicians.
The review addressed only CNMs practicing in the United States and outcomes measured during labor and delivery. The majority of study designs were observational and the models of care ranged from independent to shared, limiting the control for bias. Moreover, all reviewers were nurses.
Differences in practice between CNMs and MDs seem to be well documented, particularly in the use of technology. Yet, the findings provide evidence that care by CNMs is safe and effective. CNMs should be better utilized to address the projected health care workforce shortages.
在美国，高级执业护士（APN）可以扩大高质量医疗保健的可及性，特别是为服务不足的人群。然而，与其他提供者相比，关于他们的有效性的证据综合有限。本报告所述的研究是更大研究的一部分，该研究检查了所有四种类型的 APN，比较了认证的助产士（CNM）和医生的分娩护理结果。
PubMed、护理与联合健康文献累积索引（CINAHL）和 Proquest（用于论文）在 1990 年至 2008 年期间进行了搜索。
仅包括那些在 CNM 和医生之间定量比较护理过程或结果的文章。对于所有 APN，共审查了 27,993 篇参考文献。对于 CNM，21 篇文章代表 18 项独特的研究报告了婴儿或产妇的结果。
系统审查遵循既定程序（可重复搜索相关数据库，连续审查以确定合格研究，由两名审查员提取，质量评估和证据分级）。
对于与护理过程相关的措施（例如，硬膜外、引产、会阴切开术），CNM 的使用率较低。对于许多婴儿结局（例如，低 Apgar、低出生体重、新生儿重症监护病房入院），CNM 与医生之间没有差异。与医生相比，由 CNM 护理的妇女会阴裂伤较低，母乳喂养率较高。
该综述仅涉及在美国执业的 CNM 以及分娩期间测量的结果。大多数研究设计是观察性的，护理模式从独立到共享不等，限制了对偏倚的控制。此外，所有评论员都是护士。
CNM 和 MD 之间的实践差异似乎得到了很好的记录，特别是在技术的使用方面。然而，这些发现证明了 CNM 的护理是安全有效的。应更好地利用 CNM 来解决预计的医疗保健劳动力短缺问题。
